LIC282 Form

SECTION A:
I/We, the parent(s)/guardian(s) of: (Child's Name)

Acknowledge that (Licensee's Name)

The licensee of (Name of Family Child Care Home)

SECTION B: To be completed only if licensee does not own premises or the licensee is a member of a condominium or Homeowner's Association.

I/We, the parent(s)/guardian(s) of: (Child's Name)

Acknowledge that (Licensee's Name)

The licensee of: (Name of Family Child Care Home)

Signature of Parent(s)/Guardian(s):

Date

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